The revision date appears in the footer of the document. Links within the document are updated as changes occur throughout the year.

Transcription

1 An Independent Licensee of the Blue Cross Blue Shield Association. APPENDIX C HOME INFUSION THERAPY MANUAL This appendix to the Business Procedure Manual briefly describes home infusion therapy benefits and guidelines available to the members of Blue Cross and Blue Shield of Kansas (BCBSKS). The information applies specifically to those providing home infusion therapy services on an outpatient basis. CPT five-digit codes, nomenclature and other data are copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic unit, relative values or related lists are included in CPT. The AMA assumes no liability for the data contained herein. Acknowledgement: Current Procedural Terminology (CPT ) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable ARS/DFARS Restrictions Apply to Government Use. NOTE: The revision date appears in the footer of the document. Links within the document are updated as changes occur throughout the year. BCBSKS Business Procedure Manual Page C-1

2 TABLE OF CONTENTS Enteral Formula and Medical Supplies... Page C-3 Parenteral Nutrition Solutions and Supplies... Page C-4 Enteral and Parenteral Pumps... Page C-5 Infusion Equipment/Supplies... Page C-6 Home Infusion Therapy S Codes... Page C-7 Total Parenteral Nutrition (TPN)... Page C-8 Important Billing Reminders... Page C-9 BCBSKS Business Procedure Manual Page C-2

3 Enteral Formula and Medical Supplies HCPCS Codes B4034 B4036 Use these codes only when the all-inclusive administration/supply codes are not used. HCPCS Codes B4100 B4162 Most member contracts do not cover formula. Formula is covered for FEP members when criteria are met. (See Benefit Plan Brochure for criteria). Submit NDC number and the appropriate units based on what was purchased and the nomenclature of the code on claim attachment. Multiple units required in Box 24G if more than one unit of 100 calories per code. 200 calories = 002 units of service BCBSKS Business Procedure Manual Page C-3

4 Parenteral Nutrition Solutions and Supplies HCPCS Codes B4164 B4216 Predetermination is strongly recommended. To access the form online, go to Indicate number of cubic centimeters (cc), milliliters (ml), or grams on attached claim. Multiple units are required in Box 24G if more than one 500 ml unit per code or more than one unit of grams indicated in code. Two 500 ml units = 002 units of service Three 15 grams units = 003 units of service When using the all-inclusive S codes, standard TPN Formula should not be billed separately. HCPCS Codes B4220 B4224 If billing all-inclusive administration/supply code, list separately. HCPCS Codes B5000 B5200 Predetermination is strongly recommended. To access the form online, go to Indicate number of cc on claim attachment. Multiple units are required in Box 24G if more than one unit per code. Two 500 ml units = 002 units of service Three 15 grams units = 003 units of service BCBSKS Business Procedure Manual Page C-4

5 Enteral and Parenteral Pumps HCPCS Codes B9000 B9999 Enteral nutrition pumps for long-term use should be purchased. Rental or purchase of the pump will be at the discretion of BCBSKS. Parenteral nutrition pumps are covered for purchase or rental only if TPN is covered. If need is long term, pump should be purchased. Use modifier RR for Rental and NU for Purchase. Enternal supply NOC (not otherwise classified) should be submitted with itemization to include description and charge for each item. Routine supplies (i.e. extension sets) are part of the all-inclusive procedure codes and should not be billed under this code. Parenteral supply NOC (not otherwise classified) should be submitted with itemization to include description and charge for each item. Routine supplies (i.e. tubes) are part of the all-inclusive procedure codes and should not be billed under this code. Special tubing should be coded with: B4081 B4082 B4083 B4087 B4088 If billing all-inclusive administration/supply code, these codes should not be billed separately. When billing for a Mickey button, use NOC code with description. BCBSKS Business Procedure Manual Page C-5

6 Infusion Equipment/Supplies HCPCS Codes E0776 E0791, K0455, K0552, K0601-K0605, S1015, & S1016 Rental is allowed for short term use, subject to review. Purchase is allowed for long term use. Equipment should be submitted with the appropriate modifier: RR = Rental NU = Purchase E0776 should be billed as purchase upfront when used with enteral feeding. If billing all-inclusive administration/supply code, these codes should not be billed separately. BCBSKS Business Procedure Manual Page C-6

7 Home Infusion Therapy S Codes HCPCS Codes S5035 and S5036 Deny content of service of the rental of the pump. If pump is purchased, provide the following information on the claim attachment: Date purchased By Whom Itemize repairs All-inclusive HCPCS Codes S5497 S5502, S9061, S9325 S9363, S9370 S9379, & S9490 S9810 Include: All equipment-pump and supplies Bag and mixing fees Dispensing fee, etc. Itemization of charges is not required. Drugs should be coded separately. Indicate pump usage and route of administration on the claim attachment. When billing S9379 and S9490-S9504 on the same date of service, reimbursement will be allowed at full and ½ of the maximum allowable payment (MAP). These per diem codes are limited to one per date of service. All other per diem codes are limited to one per date of service. Include all line items for one day on the same claim. HCPCS Codes S5517-S5523 are considered content of service of catheter replacement and not reimbursed separately. Nursing visits should be precertified. Call BCBSKS Precertification at BCBSKS Business Procedure Manual Page C-7

8 Total Parenteral Nutrition (TPN) All-inclusive HCPCS codes S9364 S9368 Predetermination is strongly recommended. To access the form online, go to History and physical findings are required. The following questions should be answered: Is oral feeding impossible? Is TPN the only source of nutrition? Has enteral feeding been tried? o If yes, why did it fail? o If no, why not? If the patient is able to eat, o What is the patient s expected caloric intake? o What percent of calories is TPN going to provide? What is the rationale for needing TPN? What is the diagnosis? What is the expected duration of TPN therapy? If specialty amino acids are required, what is the medical necessity? The following drugs are included in the S code and cannot be billed separately: Non-specialty amino acids Concentrated dextrose Sterile water Electrolytes Standard multi-trace element solutions Standard multi-vitamin solutions The following drugs may be billed separately, using J3490, and the number of units implicit in the NDC number (e.g. number of vials dispensed): Specialty amino acids for renal failure, hepatic failure, high stress conditions and amino acids with concentrations of 15 percent and above when medically necessary Added trace elements not from a standard multi-trace element solution Added vitamins not from a standard multivitamin solution Products serving non-nutritional purposes (e.g. heparin, insulin, iron, dextran, famotidin, ondansetron) BCBSKS Business Procedure Manual Page C-8

9 Important Billing Reminders BlueCard member s coverage is determined by their Blue Cross Blue Shield plan. Include all line items for one day on the same claim. Submit correct place of service: 11 = office 12 = home BCBSKS Business Procedure Manual Page C-9